Surgical treatment of esophageal cancer in the era of multimodality management

Enhanced Recovery Protocol Versus Conventional Care in Patients Undergoing Esophagectomy for Cancer: Advantages in Clinical and Patient-Reported Outcomes

BACKGROUND

This study was designed to compare the clinical and patient-reported outcomes (PROs) between the enhanced recovery after surgery (ERAS) protocol and conventional care in patients undergoing esophagectomy for cancer, which have not previously been compared.

METHODS

This single-center retrospective study included prospective PRO data from August 2019 to June 2021. Clinical outcomes included perioperative complications and postoperative length of stay (PLOS). Patient-reported outcomes were assessed by using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 (QLQ-C30) and esophagus-specific module (QLQ-OES18) preoperatively to 6 months postoperatively. Mixed-effects models were used to longitudinally compare quality of life (QOL) scores between the two modes.

RESULTS

Patients undergoing conventional care and ERAS were analyzed (n = 348 and 109, respectively). The ERAS group had fewer overall complications, pneumonia, arrhythmia, and a shorter PLOS than the conventional group, and outperformed the conventional group in five functional QLQ-C30 domains and five symptom QLQ-OES18 domains, including less dysphagia (p < 0.0001), trouble talking (p = 0.0006), and better eating (p < 0.0001). These advantages persisted for 3 months postoperatively. For the cervical circular stapled anastomosis, the initial domains and duration of benefit were reduced in the ERAS group.

CONCLUSIONS

The ERAS protocol has significant advantages over conventional care in terms of clinical outcomes, lowering postoperative symptom burden, and improving functional QOL in patients who have undergone esophagectomy. Selection of the optimal technique for cervical anastomosis is a key operative component of ERAS that maintains the symptom domains and duration of the advantages of PROs.

Perioperative outcomes in patients who undergo neoadjuvant chemoradiotherapy versus chemotherapy versus up-front surgery in patients with oesophageal cancer

BACKGROUND

Oesophagectomy is the mainstay of curative treatment for oesophageal cancer. The role of neoadjuvant therapy has evolved over time as evidence for its survival benefit comes to hand. Clinician reluctance to offer patients neoadjuvant therapy may be based on the perception that patients receiving treatment before surgery may be exposed to a greater risk of perioperative complications. The aim of this study was to examine short-term outcomes in patients who undergo neoadjuvant therapy versus up-front surgery in patients with oesophageal cancer.

METHODS

This was a retrospective cohort study of prospectively collated data from 2001 to 2020 of patients undergoing resection for oesophageal cancer. Patients who had neoadjuvant chemoradiotherapy, chemotherapy and up-front surgery were compared for perioperative morbidity (via the Clavien-Dindo classification), length of stay, unplanned readmission, and 30- and 90-day mortality. Logistic regression was performed to predict perioperative morbidity following surgery.

RESULTS

In total, 284 patients underwent an oesophagectomy. Most patients received neoadjuvant treatment (41% received chemoradiotherapy (117/284), 33% received chemotherapy (93/284)), and 26% of patients received up-front surgery (74/284). Patients who received neoadjuvant chemoradiotherapy or up-front surgery were more likely to have a complication (57%, 67/117 and 57%, 43/74) than patients who received neoadjuvant chemotherapy only (38%, 35/93, P = 0.009). The 30- and 90-day mortality rates were 1.4% (n = 4) and 2.8% (n = 8), respectively, with no difference between the use of neoadjuvant therapy.

CONCLUSION

In this series, we found that patients who received neoadjuvant treatment could undergo oesophagectomy with curative intent with acceptable postoperative morbidity and mortality.

Long-term survival analysis of robotic esophagectomy for esophageal cancer

Robotic esophagectomy has improved early outcomes and enhanced the quality of lymphadenectomy for esophageal cancer surgery. This study aimed to determine risk factors for long-term survival following robotic esophagectomy and the causes of long-term mortality. We included patients who underwent robotic esophagectomy at our institute between 2010 and 2022. Robotic esophagectomy was defined as a surgical procedure performed robotically in both the abdomen and thorax. Robotic esophagectomy was performed in patients at all stages, including advanced stages, even in patients with stage IV and supraclavicular lymph node metastasis. A total of 340 patients underwent robotic esophagectomy during the study period. Ivor-Lewis operation and McKeown operation were performed on 153 (45.0%) and 187 (55.0%) patients, respectively. The five-year survival rates based on clinical stages were as follows: 85.2% in stage I, 62.0% in stage II, 54.5% in stage III, and 40.3% in stage IV. Risk factors for long-term survival included body mass index, Charlson comorbidity index, clinical stages, and postoperative complications of grade 4 or higher. Among the cases of long-term mortality, recurrence accounted for 42 patients (61.7%), while non-cancer-related death occurred in 26 patients (38.2%). The most common cause of non-cancer-related death was malnutrition and poor general condition, observed in 11 patients (16.2%). Robotic esophagectomy has demonstrated the ability to achieve acceptable long-term survival rates, even in patients with cervical lymph node metastasis. However, addressing high-grade postoperative complications and long-term malnutrition remains crucial for further improving the long-term survival outcomes of patients with esophageal cancer.

Prognostic prediction and comparison of three staging programs for patients with advanced (T2-T4) esophageal squamous carcinoma after radical resection

Purpose

Lymph node-based staging protocols are frequently employed to evaluate the prognosis of esophageal cancer, yet their accuracy remains contentious. The present study was conducted to assess the prognostic significance of three lymph node staging systems, namely N stage, lymph node rate (LNR), and log odds of positive lymph nodes (LODDS), in patients diagnosed with advanced (T2-T4) esophageal squamous cell carcinoma (ESCC).

Methods

This cohort comprised 319 eligible patients, with an additional 409 individuals retrieved from the Surveillance, Epidemiology, and End Results (SEER) database, forming the validation cohort. Differences in overall survival (OS) of patients between groups were assessed using the log-rank test. Prognostic independent risk variables were identified, and lymph nodes (LN) prognostic models were built using multivariate Cox regression analysis. Besides, the predictive accuracy of each model was evaluated utilizing the (-2) log-likelihood ratio (-2LLR), the likelihood ratio χ2 score (LRχ2), the Akaike information criterion (AIC), and Harrell's concordance index (C-index). To further evaluate the potential superiority of the model, a nomogram was constructed for comparison with the conventional Tumor Node Metastasis (TNM) staging approach.

Results

Independent prognostic factors for advanced ESCC include the N stage, LNR, and LODDS. Herein, LODDS presented higher values for C-index and LRχ2, and lower values for AIC and -2LLR in OS compared to the others. Consequently, a nomogram was constructed based on LODDS. Calibration curves exhibited strong agreement, and assessment through C-index, receiver operating characteristic (ROC) curves, and clinical decision curve analysis (DCA) demonstrated promising clinical applicability.

Conclusion

LODDS emerges as a promising future prognostic indicator. After surgery, the proposed model holds the potential to provide valuable treatment recommendations for patients with advanced ESCC.

Mapping of lymph node metastasis from esophageal squamous cell carcinoma after neoadjuvant treatment: a prospective analysis from a high-volume institution in China

The study aimed to describe the prevalence of lymph node metastases per lymph node station for esophageal squamous cell carcinoma (ESCC) after neoadjuvant treatment. Clinicopathological variables of ESCC patients were retrieved from the prospective database of the Surgical Esophageal Cancer Patient Registry in West China Hospital, Sichuan University. A two-field lymphadenectomy was routinely performed, and an extensive three-field lymphadenectomy was performed if cervical lymph node metastasis was suspected. According to AJCC/UICC 8, lymph node stations were investigated separately. The number of patients with metastatic lymph nodes divided by those who underwent lymph node dissection at that station was used to define the percentage of patients with lymph node metastases. Data are also separately analyzed according to the pathological response of the primary tumor, neoadjuvant treatment regimens, pretreatment tumor length, and tumor location. Between January 2019 and March 2023, 623 patients who underwent neoadjuvant therapy followed by transthoracic esophagectomy were enrolled. Lymph node metastases were found in 212 patients (34.0%) and most frequently seen in lymph nodes along the right recurrent nerve (10.1%, 58/575), paracardial station (11.4%, 67/587), and lymph nodes along the left gastric artery (10.9%, 65/597). For patients with pretreatment tumor length of >4 cm and non-pathological complete response of the primary tumor, the metastatic rate of the right lower cervical paratracheal lymph nodes is 10.9% (10/92) and 10.6% (11/104), respectively. For patients with an upper thoracic tumor, metastatic lymph nodes were most frequently seen along the right recurrent nerve (14.2%, 8/56). For patients with a middle thoracic tumor, metastatic lymph nodes were most commonly seen in the right lower cervical paratracheal lymph nodes (10.3%, 8/78), paracardial lymph nodes (10.2%, 29/285), and lymph nodes along the left gastric artery (10.4%, 30/289). For patients with a lower thoracic tumor, metastatic lymph nodes were most frequently seen in the paracardial station (14.2%, 35/247) and lymph nodes along the left gastric artery (13.1%, 33/252). The study precisely determined the distribution of lymph node metastases in ESCC after neoadjuvant treatment, which may help to optimize the extent of lymphadenectomy in the surgical management of ESCC patients after neoadjuvant therapy.

Influence of metabolic syndrome on prognosis of patients with surgically treated esophageal cancer: a meta-analysis

BACKGROUND

Metabolic syndrome (MetS) has been related to the increased incidence of esophageal cancer (EC). The aim of the study was to evaluate the influence of MetS on prognosis of patients with surgically treated EC in a systematic review and meta-analysis.

METHODS

An extensive search was conducted on PubMed, Embase, Web of Science, Wanfang, and CNKI to identify relevant cohort studies. Random-effects models were employed to combine the findings, taking into account the potential influence of heterogeneity.

RESULTS

Seven cohort studies involving 4332 patients with stage I-III EC who received surgical resection were included. At baseline, 608 (14.0%) patients had MetS. Pooled results suggested that MetS were associated with a higher risk of postoperative complications (risk ratio [RR]: 1.30, 95% confidence interval [CI]: 1.03 to 1.64, p = 0.03; I2 = 0%). However, the overall survival (RR: 1.07, 95% CI: 0.75 to 1.52, p = 0.71; I2 = 80%) and progression-free survival (RR: 1.27, 95% CI: 0.53 to 3.00, p = 0.59; I2 = 80%) were not significantly different between patients with and without MetS. Subgroup analyses suggested that the results were not significantly modified by study design (prospective or retrospective), histological type of EC (squamous cell carcinoma or adenocarcinoma), or diagnostic criteria for MetS (p values indicating subgroup difference all > 0.05).

CONCLUSION

Although MetS may be associated with a moderately increased risk of postoperative complications in patients with EC under surgical resection, the long-term survival may not be different between patients with and without MetS.

IL-1β promotes esophageal squamous cell carcinoma growth and metastasis through FOXO3A by activating the PI3K/AKT pathway

Esophageal cancer is a common type of cancer that poses a significant threat to human health. While the pro-inflammatory cytokine IL-1β has been known to contribute to the development of various types of tumors, its role in regulating esophageal cancer progression has not been extensively studied. Our studies found that the expression of IL-1β and FOXO3A was increased in esophageal squamous cell carcinoma (ESCC). IL-1β not only increased the proliferation, migration, and invasion of two ESCC cell lines but also promoted tumor growth and metastasis in nude mice. We also observed that IL-1β and FOXO3A regulated the process of epithelial-mesenchymal transition (EMT) and autophagy. The PI3K/AKT pathway was found to be involved in the changes of FOXO3A with the expression level of IL-1β. The AKT agonist (SC79) reversed the reduction of FOXO3A expression caused by the knockdown of IL-1β, indicating that IL-1β plays a role through the PI3K/AKT/FOXO3A pathway. Furthermore, the knockdown of FOXO3A inhibited ESCC development and attenuated the pro-cancer effect of overexpressed IL-1β. Targeting IL-1β and FOXO3A may be potentially valuable for the diagnosis and treatment of ESCC.

Feasibility of utilizing mediastinal drains alone following esophageal cancer surgery: a retrospective study

BACKGROUND

It was typically necessary to place a closed thoracic drainage tube for drainage following esophageal cancer surgery. Recently, the extra use of thoracic mediastinal drainage after esophageal cancer surgery had also become more common. However, it had not yet been determined whether mediastinal drains could be used alone following esophageal cancer surgery.

METHODS

A total of 134 patients who underwent esophageal cancer surgery in our department between June 2020 and June 2023 were retrospectively analyzed. Among them, 34 patients received closed thoracic drainage (CTD), 58 patients received closed thoracic drainage combined with mediastinal drainage (CTD-MD), while 42 patients received postoperative mediastinal drainage (MD). The general condition, incidence of postoperative pulmonary complications, postoperative NRS score, and postoperative anastomotic leakage were compared. The Mann-Whitney U tests, Welch's t tests, one-way ANOVA, chi-square tests and Fisher's exact tests were applied.

RESULTS

There was no significant difference in the incidence of postoperative hyperthermia, peak leukocytes, total drainage, hospitalization days and postoperative pulmonary complications between MD group and the other two groups. Interestingly, patients in the MD group experienced significantly lower postoperative pain compared to the other two groups. Additionally, abnormal postoperative drainage fluid could be detected early in this group. Furthermore, there was no significant change in the incidence of postoperative anastomotic leakage and the mortality rate of patients after the occurrence of anastomotic leakage in the MD group compared with the other two groups.

CONCLUSIONS

Using mediastinal drain alone following esophageal cancer surgery was equally safe. Furthermore, it could substantially decrease postoperative pain, potentially replacing the closed thoracic drain in clinical practice.

Calcifications in the descending thoracic aorta predict postoperative anastomotic leakages after esophagectomy for cancer

BACKGROUND

Anastomotic leak is one of the most feared complications of esophagectomy. Previous studies have suggested a potential link between aortic calcifications detected on routine preoperative CT scans and increased risk of anastomotic leak after esophagectomy. This study aims to investigate whether clinicians' assessment of aortic calcifications can predict the occurrence of anastomotic leaks in patients undergoing esophagectomy for cancer.

METHODS

A long-term follow-up was conducted on consecutive patients with esophageal cancer who underwent elective open esophagectomy at a Finnish tertiary hospital. Aortic calcifications were evaluated based on CT scans and categorized on a 0-3 scale reflecting the number of calcifications in the affected segment of the aorta. Reviewers assessing the calcifications were blinded to clinical details and postoperative outcomes.

RESULTS

The study included 97 patients (median age: 64 years and range: 43-78; 20% female), with a median follow-up time of 1307 (2-1540) days. Among them, 22 patients (23%) had postoperative anastomotic leak. We observed a significant association between calcifications in the descending aorta and a higher risk of anastomotic leak (p = 0.007), as well as an earlier occurrence of leak postoperatively (p = 0.013). However, there was no association between aortic calcifications and increased mortality.

CONCLUSIONS

Presence of calcifications in the descending aorta is independently associated with an increased risk of anastomotic leaks following esophagectomy for cancer. Identifying patients at higher risk for this complication could facilitate appropriate pre- and postoperative interventions, as well as enable earlier diagnosis and treatment to mitigate the severity of the complication.

A approach of gastric conduit via the anterior of pulmonary hilum route during minimally invasive McKeown esophagectomy

BACKGROUND

The gastric conduit is the most commonly used replacement organ for reconstruction after minimally invasive McKeown esophagectomy. Although the optimal route of gastric conduit remains controversial, the posterior mediastinal route is physiologically preferable but is not without disadvantages. Here, we report the safety and efficacy of a method of gastric conduit reconstruction via the anterior of the pulmonary hilum route.

METHODS

We have used the anterior of the pulmonary hilum route since 2021. This procedure involves pulling the gastric conduit up through a substernal tunnel between the right thoracic cavity and the abdominal cavity and passing it into the neck via the anterior of the pulmonary hilum route. In this retrospective study, we compared the clinical outcomes between 20 patients who underwent this procedure and 20 patients who underwent the posterior mediastinal route from 2021 to 2022.

RESULTS

No mortality was reported in either group. No significant differences were observed between the two groups in duration of surgery, blood loss, incidence of postoperative complications, and postoperative hospital stay. As a result of the anterior of the pulmonary hilum route, the primary tumor bed and lymph node drainage area were effectively bypassed, which facilitates postoperative adjuvant radiotherapy or chemoradiotherapy. The distance of the gastric conduit accompanying the airway was significantly shorter in the anterior of the pulmonary hilum route group.

CONCLUSIONS

Our method is considered to be a safe and useful technique for the reconstruction of gastric conduit.

Impact of weekday of esophageal cancer surgery on long-term oncological outcomes

BACKGROUND

Studies about the influence of weekday of esophagectomy on survival are limited and show conflicting results. This study aimed to explore whether weekday of esophagectomy affects patient's survival outcomes.

METHODS

Patients who underwent esophagectomy in a grade-A tertiary hospital from January 2015 to December 2016 were enrolled. The primary outcome was 5-year overall survival (OS). The secondary outcomes were 5-year disease-free survival (DFS) and days of hospitalization. The impact of weekday surgery on 5-year OS and DFS were evaluated with Cox regression, and impact on days of hospitalization was assessed using logistic regression. Propensity score matching (PSM) analysis was used to balance the confounding factors.

RESULTS

A total of 1478 patients were included. The 5-year OS and DFS were 63.77% and 59.26% respectively. Multivariate analyses adjusted for covariables indicated that weekday was not significantly associated with OS (P = 0.076), nor days of hospitalization (P = 0.824), but it appeared to be associated with DFS (P = 0.044). Additionally, PSM analysis showed no significant effect of weekday on the 5-year OS, nor DFS and days of hospitalization.

CONCLUSION

In patients diagnosed with squamous esophageal cancer, the survival outcome of patients was not influenced by weekday.

A rare case of carcino-sarcoma of the esophagus with huge intrathoracic metastasis

Carcinosarcoma of the esophagus constitutes only 0.5%-2.8% of all malignant esophageal cancers. It is identified by the presence of both carcinomatous and sarcomatous components. A clear regimen of treatment has not been established due to the limited understanding of the disease. We present a case of carcinosarcoma of the esophagus with rapid recurrence and invasion to the intrathoracic cavity only 6 weeks after esophagectomy. Carcinosarcoma carries a poor prognosis, as it has a late tendency of hematogenous spread with a high growth rate.

Short-term outcomes of robot-assisted versus conventional minimally invasive esophagectomy for esophageal cancer: a systematic review and meta-analysis of 18,187 patients

The role of robotic surgery in the curative-intent treatment of esophageal cancer patients is yet to be defined. To compare short-term outcomes between conventional minimally invasive (cMIE) and robot-assisted minimally invasive esophagectomy (RAMIE) in esophageal cancer patients. PubMed, Web of Science and Cochrane Library were systematically searched. The included studies compared short-term outcomes between cMIE and RAMIE. Individual risk of bias was calculated using the MINORS and RoB2 scales. There were no statistically significant differences between RAMIE and cMIE regarding conversion to open procedure, mean number of harvested lymph nodes in the mediastinum, abdomen and along the right recurrent laryngeal nerve (RLN), 30- and 90-day mortality rates, chyle leakage, RLN palsy as well as cardiac and infectious complication rates. Estimated blood loss (MD - 71.78 mL, p < 0.00001), total number of harvested lymph nodes (MD 2.18 nodes, p < 0.0001) and along the left RLN (MD 0.73 nodes, p = 0.03), pulmonary complications (RR 0.70, p = 0.001) and length of hospital stay (MD - 3.03 days, p < 0.0001) are outcomes that favored RAMIE. A significantly shorter operating time (MD 29.01 min, p = 0.004) and a lower rate of anastomotic leakage (RR 1.23, p = 0.0005) were seen in cMIE. RAMIE has indicated to be a safe and feasible alternative to cMIE, with a tendency towards superiority in blood loss, lymph node yield, pulmonary complications and length of hospital stay. There was significant heterogeneity among studies for some of the outcomes measured. Further studies are necessary to confirm these results and overcome current limitations.

Development of a Survival Nomogram for Esophageal Squamous Cell Carcinoma Patients: a Population-Based Analysis

PURPOSE

In this study, we developed a prognostic nomogram for esophageal squamous cell carcinoma (ESCC) patients.

METHODS

Patients diagnosed with ESCC from the Surveillance, Epidemiology, and End Results (SEER) database (1975-2017) and a local hospital were enrolled in this retrospective cohort study. Prognoses were analyzed using the R language software, and the predictive power of the model was then assessed by the Harrell concordance index (C-index) and the area under the curve (AUC) of the receiver operating characteristic (ROC) curve.

RESULTS

In total, 2915 ESCC patients from SEER database were divided into training and validation cohorts. Multivariate analysis revealed that sex, marital status, tumor-node-metastasis (TNM) stage, surgery, chemotherapy, and radiation all showed a significant association with overall survival (OS) and cancer-specific survival (CSS) (also with tumor grade). These characteristics were employed to build a nomogram. The C-index of the nomogram for OS and CSS prediction was 0.743 and 0.748 for the training cohort, which were superior to the predictive power of the 7th TNM staging system. The AUCs of the nomogram for predicting 2- and 5-year OS were 0.805 and 0.812, respectively, and the AUCs for CSS were 0.811 and 0.821, respectively. ROC and calibration curves of data from the SEER internal validation set and of data from our hospital showed that this model had good accuracy for predicting the prognosis of ESCC patient.

CONCLUSION

The nomogram developed in this study provides a useful tool for accurately estimating OS and CSS for ESCC patients.

T-cell exhaustion prediction algorithm in tumor microenvironment for evaluating prognostic stratification and immunotherapy effect of esophageal cancer

Esophageal cancer (EC) is a common digestive malignancy that ranks sixth in cancer deaths, with a 5-year survival rate of 15%-25%. As a result, reliable prognostic biomarkers are required to accurately predict the prognosis of EC. T-cell exhaustion (TEX) is associated with poorer prognosis and immune infiltration in EC. In this study, nine risk genes were finally screened to constitute the prognostic model using least absolute shrinkage and selection operator analysis. Patients were divided into two groups based on the expression of the TEX-related genes: high-risk group and low-risk group. The expression of TEX-related genes differed significantly between the two groups. The findings revealed that the risk model developed was highly related to the clinical prognosis and amount of immune cell infiltration in EC patients. It was also significantly correlated with the therapeutic sensitivity of multiple chemotherapeutic agents in EC patients. Subsequently, we successfully constructed drug-resistant cell lines KYSE480/CDDP-R and KYSE180/CDDP-R to verify the correlation between PD-1 and drug resistance in EC. Then, we examined the mRNA and protein expression levels of PD-1 in parental and drug-resistant cells using qPCR and WB. It was found that the expression level of PD-1 was significantly increased in the plasma red of drug-resistant cells. Next, we knocked down PD-1 in drug-resistant cells and found that the resistance of EC cells to CDDP was significantly reduced. And the proportion of apoptotic cells in cells treated with 6 μM CDDP for 24 h was significantly in increase. The TEX-based risk model achieved good prediction results for prognosis prediction in EC patients. And it was also significantly associated with the level of immune cell infiltration and drug therapy sensitivity of EC patients. Additionally, the downregulation of PD-1 may be associated with increased drug sensitivity in EC and enhanced T-cell infiltration. The high-risk group had lower TIDE scores, indicating that the high-risk group benefits more after receiving immunotherapy. Thus, the TEX-based risk model can be used as a novel tumor prognostic biomarker.

Esophageal Carcinoma in Children: Report of 2 Cases and a Review of the Literature

Esophageal carcinoma in children and adolescents is extremely rare. Here, we report 2 cases of pediatric esophageal carcinoma presenting with progressive dysphagia. There was not any underlying specific risk factor in our cases. The histopathological subtypes were adenocarcinoma in one and squamous cell carcinoma in another case. Response to combined modality treatment was good in the case of adenocarcinoma, while the patient with squamous cell carcinoma was unresponsive to treatment and died of the progressive disease. We reviewed the pediatric cases of esophageal carcinoma reported in the literature. Progressive dysphagia was observed in 89% of these cases. One third of pediatric cases had underlying risk factors. Squamous cell carcinoma is a more common type of childhood esophageal carcinoma. In contrast to adults, pediatric esophageal squamous cell carcinoma may distribute throughout the esophagus. Esophageal adenocarcinoma was seen in the distal esophagus in pediatric cases. Metastatic disease was found in 48% of pediatric patients at presentation, and the prognosis is poor. Collaborative efforts are needed for success in the treatment of esophageal carcinoma.

Global trends in esophageal cancer mortality with predictions to 2025, and in incidence by histotype

BACKGROUND

Esophageal cancer (EC) is a malignancy with a poor prognosis. We provided a global overview of EC mortality, analyzing figures over the last three decades and estimating mortality rates for the year 2025. We also reported incidence trends and the distribution of squamous cell carcinoma (SCC) and adenocarcinoma (AC) in selected countries.

METHODS

We considered EC trends in the age-standardised mortality rates (ASMR) from the World Health Organization database for selected countries. To estimate the number of deaths and ASMRs for 2025, we applied a Poisson linear regression model to the latest trend segment identified using a joinpoint model. We reported EC incidence trends according to histology using the Cancer Incidence in Five Continents database for the calendar period of 1990-2012.

RESULTS

In 2015-19, the male ASMRs/100,000 were 4.01 in the EU-27, 4.28 in the USA, and 5.10 in Japan. The corresponding female rates ranged from 0.82 to 0.85/100,000. Male mortality showed a decreasing trend in most countries analyzed, with earlier and steeper declines in southern Europe. Conversely, ASMRs were increasing in Belarus, Finland, Greece, and Cuba. Female mortality showed a slight increase in several European countries, while North America, Latin America, and Australasia showed favorable trends. Projections suggest that male EC mortality is expected to decline in all countries except the Russian Federation. Female favorable trends are also predicted in most countries, except for France, Germany, the Russian Federation, and Canada. SCC remained the most common histotype, but AC incidence showed an upward trend, particularly in high-income countries.

CONCLUSION

The observed trends in EC mortality reflect variations in patterns of major risk factors. Effective control of risk factors would contribute to reducing the burden of EC, together with early diagnosis and potential improvements in treatments.

The impact of refusing esophagectomy for treatment of locally advanced esophageal adenocarcinoma

Objective

Patients with esophageal cancer may be reluctant to proceed with surgery due to high complication rates. This study aims to compare outcomes between eligible surgical candidates who proceeded with surgery versus those who refused surgery.

Methods

Characteristics and survival of patients with locally advanced (cT3N0M0, cT1-3N+M0) mid-/distal esophageal adenocarcinoma in the National Cancer Database (2006-2019) who either proceeded with or refused surgery after chemoradiotherapy were evaluated with logistic regression, Kaplan-Meier curves, and Cox proportional hazards methods.

Results

Of the 13,594 patients included in the analysis, 595 (4.4%) patients refused esophagectomy. Patients who refused surgery were older, had less distance to travel to their treatment facility, were more likely to have cN0 disease, and were more likely to be treated at a community rather than academic or integrated network program, but did not have significantly different comorbid disease distributions. On multivariable analysis, refusing surgery was independently associated with older age, uninsured, lower income, less distance to a hospital, and treatment in a community program versus an academic/research or integrated network program. Esophagectomy was associated with better survival (5-year survival 40.1% [39.2-41] vs 23.6% [19.9-27.9], P < .001) and was also independently associated with better survival in the Cox model (hazard rate, 0.78 [95% confidence interval, 0.7-0.87], P < .001).

Conclusions

The results of this study can inform selected patients with resectable esophageal adenocarcinoma that their survival will be significantly diminished if surgery is not pursued. Many factors associated with refusing surgery are non-clinical and suggest that access to or support for care could influence patient decisions.

Reducing Conduit Ischemia and Anastomotic Leaks in Transhiatal Esophagectomy: Six Principles

BACKGROUND

Transhiatal esophagectomy (THE) is an accepted approach for distal esophageal (DE) and gastroesophageal junction (GEJ) cancers. Its reported weaknesses are limited loco-regional resection and high anastomotic leak rates. We have used laparoscopic assistance to perform a THE (LapTHE) as our preferred method of resection for GEJ and DE cancers for over 20 years. Our unique approach and experience may provide technical insights and perhaps superior outcomes.

METHODS

We reviewed all patients who underwent LapTHE for DE and GEJ malignancy over 10 years (2011-2020). We included 6 principles in our approach: (1) minimize dissection trauma using laparoscopy; (2) routine Kocher maneuver; (3) division of lesser sac adhesions exposing the entire gastroepiploic arcade; (4) gaining excess conduit mobility, allowing resection of proximal stomach, and performing the anastomosis with a well perfused stomach; (5) stapled side-to-side anastomosis; and (6) routine feeding jejunostomy and early oral diet.

RESULTS

One hundred and forty-seven patients were included in the analysis. The median number of lymph nodes procured was 19 (range 5-49). Negative margins were achieved in all cases (95% confidence interval [CI] 98-100%). Median hospital stay was 7 days. Overall major complication rate was 24% (17-32%), 90-day mortality was 2.0% (0.4-5.8%), and reoperation was 5.4% (2.4-10%). Three patients (2.0%, 0.4-5.8%) developed anastomotic leaks. Median follow-up was 901 days (range 52-5240). Nine patients (6.1%, 2.8-11%) developed anastomotic strictures.

CONCLUSIONS

Routine use of LapTHE for DE and GEJ cancers and inclusion of these six operative principles allow for a low rate of anastomotic complications relative to national benchmarks.

Journey Through Words: Exploring Esophageal Cancer in Literature

Esophageal cancer is a significant global health challenge, characterized by its aggressive nature and high mortality rates. The disease disproportionately affects males and ranks among the leading causes of cancer-related deaths worldwide. Alarming projections indicate that the prevalence of esophageal cancer is expected to surge by approximately 140% by the year 2025. This trend starkly contrasts with the anticipated decline in incidence observed for many other types of cancers. The cancer manifests primarily in two major subtypes: esophageal squamous cell carcinoma and adenocarcinoma, each with distinct epidemiological and biological characteristics. This review provides an in-depth exploration of the risk factors, anatomy, clinical presentation, diagnosis, staging, prognosis, treatment modalities, recurrence, advancements, and emerging therapies in esophageal cancer. Additionally, preventive and early detection strategies are discussed, focusing on primary, secondary, and tertiary prevention approaches. A comprehensive understanding of esophageal cancer is vital for formulating effective management strategies and improving patient outcomes.

Unveiling Therapeutic Targets for Esophageal Cancer: A Comprehensive Review

Esophageal cancer is a highly aggressive and deadly disease, ranking as the sixth leading cause of cancer-related deaths worldwide. Despite advances in treatment, the prognosis remains poor. A multidisciplinary approach is crucial for achieving complete remission, with treatment options varying based on disease stage. Surgical intervention and endoscopic treatment are used for localized cancer, while systemic treatments like chemoradiotherapy and targeted drug therapy play a crucial role. Molecular markers such as HER2 and EGFR can be targeted with drugs like trastuzumab and cetuximab, and immunotherapy drugs like pembrolizumab and nivolumab show promise by targeting immune checkpoint proteins. Epigenetic modifications offer new avenues for targeted therapy. Treatment selection depends on factors like stage, tumor location, and patient health, with post-operative and rehabilitation care being essential. Early diagnosis, appropriate treatment, and supportive care are key to improving outcomes. Continued research is needed to develop effective targeted drugs with minimal side effects. This review serves as a valuable resource for clinicians and researchers dedicated to enhancing esophageal cancer treatment outcomes.

Revolutionizing healthcare by use of artificial intelligence in esophageal carcinoma - a narrative review

Esophageal cancer is a major cause of cancer-related mortality worldwide, with significant regional disparities. Early detection of precursor lesions is essential to improve patient outcomes. Artificial intelligence (AI) techniques, including deep learning and machine learning, have proved to be of assistance to both gastroenterologists and pathologists in the diagnosis and characterization of upper gastrointestinal malignancies by correlating with the histopathology. The primary diagnostic method in gastroenterology is white light endoscopic evaluation, but conventional endoscopy is partially inefficient in detecting esophageal cancer. However, other endoscopic modalities, such as narrow-band imaging, endocytoscopy, and endomicroscopy, have shown improved visualization of mucosal structures and vasculature, which provides a set of baseline data to develop efficient AI-assisted predictive models for quick interpretation. The main challenges in managing esophageal cancer are identifying high-risk patients and the disease's poor prognosis. Thus, AI techniques can play a vital role in improving the early detection and diagnosis of precursor lesions, assisting gastroenterologists in performing targeted biopsies and real-time decisions of endoscopic mucosal resection or endoscopic submucosal dissection. Combining AI techniques and endoscopic modalities can enhance the diagnosis and management of esophageal cancer, improving patient outcomes and reducing cancer-related mortality rates. The aim of this review is to grasp a better understanding of the application of AI in the diagnosis, treatment, and prognosis of esophageal cancer and how computer-aided diagnosis and computer-aided detection can act as vital tools for clinicians in the long run.

Risk factors for the development of postoperative atrial fibrillation after esophagectomy for esophageal cancer

Postoperative atrial fibrillation (POAF) is one of the most complications after esophagectomy. Thus, our study was conducted to explore risk factors that are associated with POAF following esophagectomy. In the current study, we retrospectively evaluated 511 patients with esophageal cancer who underwent esophagectomy at our center between May 2018 and December 2020. The incidence of POAF and clinical variables were collected and analyzed. POAF occurred in 62 (12.13%) of 511 patients. Increasing age (P = .004) and lower preoperative albumin level (P = .028) was significantly associated with POAF. The length of stay was significantly increased in patients with POAF when compared to patients without POAF (P = .003). Multivariate analysis suggested that age (odds ratio [OR] = 1.049, 95% confidence interval [CI] = 1.008-1.093, P = .020), hypertension (OR = 2.207, 95% CI = 1.221-3.987, P = .009), respiratory complications (OR = 2.015, 95% CI = 1.130-3.591, P = .018) and Ivor Lewis approach (OR = 3.001, 95% CI = 1.032-8.723, P = .044) were independent risk factors for POAF following esophagectomy. Increasing age, preoperative hypertension, respiratory complications and Ivor Lewis approach are independent risk factors for POAF after esophagectomy. POAF is associated with prolonged length of stay. This study suggests that older patients, patients with hypertension or patients underwent Ivor Lewis approach should be monitored more closely during the postoperative period.

Patients with Isolated Brain Metastases from Esophageal Carcinoma After Minimally Invasive Esophagectomy May Not Have a Dismal Prognosis

BACKGROUND

After esophagectomy for esophageal carcinoma, 2-13% of patients develop brain metastases (BM) which are associated with a poor prognosis. Further investigation into treatment and prognosis is beneficial given the limited available literature and varying outcomes.

METHODS

Case files of all 339 patients who underwent minimally invasive esophagectomy (MIE) in a single high-volume center between January 2015 and December 2020 were retrospectively reviewed. Patients with BM and isolated brain metastases (iBM) were identified and a survival analysis was performed.

RESULTS

Fifteen out of 339 patients (4,4%) undergoing MIE developed BM of which 9 (60,0%) had iBM. Most patients were diagnosed with squamous cell carcinoma (55,6%), localized in the middle third of the esophagus (66,7%), and had a pathologic complete response (66,7%) after initial treatment. Treatment of iBM consisted of gamma knife (GK) radiosurgery (44,4%), surgical resection (22,2%), GK and surgical resection (11,1%), and best supportive care (22,2%). Median time to diagnose iBM was 8,4 months (range 0,2-37,5) and survival after detection of iBM was 14,3 months (95% CI 0,0-45.9). The 2-year survival rate after detection of iBM was 44,4%.

CONCLUSIONS

iBM after esophagectomy for esophageal carcinoma is rare, but when encountered can and should be treated with a curative intent in selected cases in close collaboration with large neurosurgical centers. A large-scale study should be conducted to confirm our findings.

MUC13 promotes the development of esophageal cancer by upregulating the expression of O-glycan process-related molecules

BACKGROUND

Esophageal cancer is one of the most common malignant tumors in the world, which is characterized by poor prognosis, aggressiveness, and poor survival. Mucin 13 (MUC13) is a member of the membrane-bound mucin and located on chromosome 3q21.2 and consists of α and β subunits. It has been found that MUC13 is overexpressed in a variety of tumor cells and acts a vital role in the invasiveness and malignant progression of several types of tumors. However, the role and regulatory mechanism of MUC13 in the progression of esophageal cancer remain unclear.

METHODS

The expression level of MUC13 was detected in 15 esophageal cancer tissues and 15 pairs of adjacent nontumor tissues by immunohistochemistry (IHC). In addition, the expression of MUC13 mRNA level in human esophageal cancer cell lines (EC9706 and ECA109 and TE-1) was measured by qRT-PCR. In vitro, after silencing MUC13 with lentiviral interference technology, CCK8 assay, clone formation assay, and flow cytometry were applied to investigate the proliferation activity, clone formation ability and anti-apoptosis ability of EC9706 and ECA109 cells. The tumor xenograft growth assay was used to confirm the influence of MUC13 knockdown on the growth of esophageal tumors in vivo. The qRT-PCR assay and western blot experiments were taken to study the mechanism of MUC13 regulating the proproliferation and antiapoptotic of esophageal cancer.

RESULTS

The results showed that MUC13 was overexpressed in esophageal cancer tissues and cell lines (EC9706 and ECA109 and TE-1), especially in EC9706 and ECA109 cells, but low expressed in human esophageal epithelial cell line (HEEC). Next, silencing MUC13 inhibits proliferation, blocks cell cycle progression, and promotes cell apoptosis in vitro, and restrains the growth of esophageal cancer tissues in vivo. Finally, MUC13 affects the proproliferation and antiapoptotic by regulating the expression of GLANT14, MUC3A, MUC1, MUC12, and MUC4 that closely related to O-glycan process.

CONCLUSIONS

This study proved that MUC13 is an important molecule that regulates the O-glycan process and then affects the progress of esophageal cancer. MUC13 may be a novel therapeutic target for patients with esophageal cancer.

Association between preoperative diagnosis of sarcopenia and postoperative pneumonia in resectable esophageal squamous cell carcinoma patients: a retrospective cohort study

Background

Postoperative outcomes for patients suffering from resectable esophageal squamous cell carcinoma (ESCC) are related to sarcopenia. In patients with resectable ESCC, this study investigated the link between sarcopenia and postoperative pneumonia.

Methods

The McKewon procedure was the only one used to treat resectable ESCC patients from January 2018 to December 2021 in this retrospective analysis. Sarcopenia was assessed using skeletal muscles at L3 and planning CT scans. It was defined when PMI was below 6.36 cm²/m² and 3.92 cm²/m² for men and women, separately. Analyses of multivariate and univariate logistic regression were applied for identifying the risk factors for postoperative pneumonia.

Results

The study included 773 patients with resectable ESCC in total. Sarcopenia was an independent risk factor for postoperative pneumonia in individuals with resectable ESCC based on univariate and multivariate analysis (P < 0.05). The stratified analysis indicated that neither of the clinical outcomes in the logistic regression model were affected by gender, age, BMI, smoking, or pre-albumin (P for interaction > 0.006).

Conclusion

Following the McKewon procedure, patients with resectable ESCC who were sarcopenic had a higher postoperative pneumonia rate. To prevent the development of postoperative pneumonia during the perioperative period, it may be important to control the incidence of sarcopenia.

The effect of a modified perioperative management model on the mental state, quality of life, and self-care ability score of patients after radical prostatectomy: A retrospective study

To explore the effects of an improved perioperative management model on the mental state, quality of life, and self-care ability scores of patients after radical prostatectomy. Overall, 96 postoperative prostate cancer patients admitted to our hospital between November 2019 and May 2021 were retrospectively analyzed and classified into an observation group and a control group with 48 patients each, according to the management model they received. The patients in the control group received routine care and were discharged. The observation group implemented an improved perioperative management model than the control group. Differences in mental state, quality of life, and self-care ability scores between the 2 groups were compared. After nursing, the self-rating anxiety scale and self-rating depression scale scores of the 2 groups were significantly lower than those before nursing, and the observation group's self-rating anxiety scale and self-rating depression scale scores were significantly lower than those of the control group (P < .05). Regarding emotion, cognition, and society, the observation group's quality of life scores was significantly higher than those of the control group. In contrast, overall health was significantly lower than that of the control group (P < .05). After nursing, the observation group's self-care skills, self-responsibility, health knowledge, and self-concept scores were significantly better than those of the control group (P < .05). The improved prostate cancer perioperative management model helps improve patients' unhealthy mental state, quality of life, self-care ability, and provides guidelines for the clinical care of patients after prostate cancer surgery.

Longer interval between neoadjuvant chemoradiotherapy and surgery is associated with improved pathological response, but does not accurately estimate survival in patients with resectable esophageal cancer

Neoadjuvant chemoradiotherapy (nCRT) has been shown to reduce tumor burden and achieve tumor regression in patients with esophageal cancer (ESC). However, the most beneficial time interval between the administration of nCRT and surgery remains unclear. Therefore, the aim of the present study was to explore the association of the duration of time between nCRT and surgery with the prognosis of patients with ESC. Patients with ESC who received nCRT following surgical resection (n=161) were reviewed and divided into the prolonged time interval group (time interval ≥66 days) and the short time interval group (time interval <66 days), according to the median value. Subsequent analysis revealed that the prolonged time interval group achieved a higher pathological complete response (pCR) rate compared with the short time interval group (49.4 vs. 26.3%; P=0.003). Furthermore, multivariate logistic regression analysis showed that it was possible to independently estimate a higher pCR rate based on a prolonged time interval (odds ratio, 2.131; P=0.042). However, no association between a prolonged time interval and disease-free survival (DFS) was detected using Kaplan-Meier curves (P=0.252) or multivariate Cox regression (P=0.607) analyses. Similarly, no association was identified between a prolonged time interval and overall survival (OS; P=0.946) based on Kaplan-Meier curve analysis, and subsequent multivariate Cox regression analyses showed that the time interval also failed to independently estimate OS (P=0.581). Moreover, female sex (P=0.001) and a radiation dose ≥40 Gy (P=0.039) served as independent factors associated with a higher pCR rate, and the pCR rate was an independent predictor of favorable DFS (P=0.002) and OS (P=0.015) rates. In conclusion, the present study revealed that a prolonged time interval from nCRT to surgery was associated with a higher pCR rate, but it failed to estimate the survival profile of patients with ESC.

Circ_0058063 regulates the development of esophageal cancer through miR-377-3p/HOXA1 axis

Esophageal cancer is one of the deadliest cancers. Circular RNA (CircRNA) can be used as a tumor marker. Therefore, this provides an important idea for our research. Real-time quantitative PCR (RT-qPCR) was used to analyze the expression of circ_0058063, miR-377-3p and homeobox protein Hox-A1 (HOXA1), western blot was used to analyze the protein levels of HOXA1 and cyclinD1, B cell leukemia/lymphoma 2 associated X (Bax). Cell Counting Kit-8 (CCK-8) assay, colony formation assay and wound healing assay were used to analyze cell proliferation and migration; apoptosis was analyzed by flow cytometry. Dual-luciferase reporter assays were performed to analyze the luciferase activities. Transwell assay was used to analyze the cell invasion. A glycolysis metabolism assay was used to analyze cell glycolysis ability. Xenograft models were used to validate the effect of circ_0009035 in the growth of esophageal cancer in vivo . Circ_0009035 and HOXA1 were upregulated, while miR-377 was downregulated in esophageal cancer.. Circ_0058063 targeted miR-377-3p, and HOX4 was a target of miR-377-3p. Knockdown of circ_0058063 inhibited migration, invasion and proliferation and promoted apoptosis of esophageal cancer cells. MiR-377-3p inhibition or HOXA1 overexpression could restore the effect of si-circ_0058063 on esophageal cancer cells. Knockdown of circ_0058063 repressed the growth of esophageal cancer tumors in vivo. Our study found that circ_0058063 could regulate the expression of HOXA1 by targeting miR-377-3p, thereby affecting the progress of esophageal cancer.

Identification of Metastatic Lymph Nodes Using Indocyanine Green Fluorescence Imaging

Indocyanine green (ICG) has been used to detect several types of tumors; however, its ability to detect metastatic lymph nodes (LNs) remains unclear. Our goal was to determine the feasibility of ICG in detecting metastatic LNs. We established a mouse model and evaluated the potential of ICG. The feasibility of detecting metastatic LNs was also evaluated in patients with lung or esophageal cancer, detected with computed tomography (CT) or positron-emission tomography (PET)/CT, and scheduled to undergo surgical resection. Tumors and metastatic LNs were successfully detected in the mice. In the clinical study, the efficacy of ICG was evaluated in 15 tumors and fifty-four LNs with suspected metastasis or anatomically key regional LNs. All 15 tumors were successfully detected. Among the fifty-four LNs, eleven were pathologically confirmed to have metastasis; all eleven were detected in ICG fluorescence imaging, with five in CT and seven in PET/CT. Furthermore, thirty-four LNs with no signals were pathologically confirmed as nonmetastatic. Intravenous injection of ICG may be a useful tool to detect metastatic LNs and tumors. However, ICG is not a targeting agent, and its relatively low fluorescence makes it difficult to use to detect tumors in vivo. Therefore, further studies are needed to develop contrast agents and devices that produce increased fluorescence signals.

Pain management after robot-assisted minimally invasive esophagectomy

Background

Adequate pain control after open esophagectomy is associated with reduced complications, earlier recovery and higher patient satisfaction. While further developing surgical procedures like robot-assisted minimally invasive esophagectomy (RAMIE) it is relevant to adapt postoperative pain management. The primary question of this observational survey was whether one of the two standard treatments, thoracic epidural analgesia (TEA) or intravenous patient-controlled analgesia (PCA), is superior for pain control after RAMIE as the optimal pain management for these patients still remains unclear. Use of additional analgesics, changes in forced expiratory volume in 1 s (FEV1), postoperative complications and duration of intensive care and hospital stay were also analyzed.

Methods

This prospective observational pilot study analyzed 50 patients undergoing RAMIE (postoperative PCA with piritramide or TEA using bupivacaine; each n = 25). Patient reported pain using the numeric rating scale score and differences in FEV1 using a micro spirometer were measured at postoperative day 1, 3 and 7. Additional data of secondary endpoints were collected from patient charts.

Results

Key demographics, comorbidity, clinical and operative variables were equivalently distributed. Patients receiving TEA had lower pain scores and a longer-lasting pain relief. Moreover, TEA was an independent predictive variable for reduced length of hospital stay (HR -3.560 (95% CI: -6.838 to -0.282), p = 0.034).

Conclusions

Although RAMIE leads to reduced surgical trauma, a less invasive pain therapy with PCA appears to be inferior compared to TEA in case of sufficient postoperative analgesia and length of hospital stay. According to the results of this observational pilot study analgesia with TEA provided better and longer-lasting pain relief compared to PCA. Further randomized controlled trials should be conducted to evaluate the optimal postoperative analgesic treatment for RAMIE.

Prone position thoracoscopic-assisted total mesoesophageal excision: initial experiences and benefits of lymph node dissection

OBJECTIVE

Total mesoesophageal excision (TME) is a promising procedure. Prone position thoracoscopic-assisted TME might be a good choice, even without robust evidence yet. Therefore, it is necessary to explore the safety and efficacy of this procedure.

METHODS

We retrospectively analyzed the short-term outcomes regarding intraoperative unplanned events, postoperative complications, and lymphadenectomy in 61 patients who underwent prone position thoracoscopic-assisted TME from June, 2020 to August, 2021. The learning curve was also defined.

RESULTS

Of these sixty-one patients, there were 10, 24 and 27 cases of tumor in the upper, middle, and lower thoracic, respectively. Although there were five cases of unplanned events during surgery, no conversion to thoracotomy occurred. The median thoracic operation time was 113(43-161) minutes, R0 resection rate was 93.4% (57/61), and negative circumferential resection margin rate was 96.7% (59/61). Median overall lymph node dissection was 21(9-47), with 13(5-41) thoracic lymph node dissection. Incidence of postoperative pulmonary complications, cardiovascular complications, and leakage were 9.8%, 3.3%, and 9.8%, respectively, with no death within 30 days after operation. The positive rate of middle and lower mediastinal lymph nodes was 1.1%, 3.5%, and 2.4% for upper, middle, and lower tumors, and 5.5%, 1.8%, and 1.3% for pT3-4, pT2, and pT1 patients. Learning curve showed that 36 cases are the best cut-off value for proficiency of prone position thoracoscopic-assisted TME.

CONCLUSIONS

The prone position thoracoscopic-assisted TME is a safe procedure that is more conducive to thoracic lymph node dissection, especially for middle and lower mediastinum.

Post-esophagectomy Anastomosis Leak: A 10-Year Experience at a Specialized Center for Cancer Surgeries in Pakistan

Esophageal cancer has been reported to be the seventh most common cancer and the sixth most common cause of mortality. Use of advanced diagnostic techniques has increased the detection of preoperative metastases and resulted in better patient selection for further management by curative surgery. We carried out a study to evaluate the outcome of esophagectomy at our institute in terms of acute leak, mortality and hospital stay. We also looked at various preoperative, intraoperative and postoperative risk factors contributing to leak after esophagectomy. We evaluated 589 patients during the period from January 2009 to December 2019. All these patients underwent elective esophagectomy for esophageal cancer at our hospital. Out of these, leak was seen in 30 patients (5.1%). We found no statistically significant difference when evaluating patient and tumour characteristics of patients who developed leak against those who did not. We also didn't find any significant difference in intraoperative or postoperative factors between the two groups. Proper preoperative evaluation and optimization are necessary to overcome various patient co-morbidities. On the basis of our study we conclude that when performed in high-volume centers with an adequately trained multi-disciplinary team approach, esophagectomy for carcinoma has a good outcome.

Thoracolaparoscopic esophagectomy for esophageal cancer with a cervical incision to extract specimen

BACKGROUND

Surgical treatment is the most important and effective therapy for resectable esophageal cancer. Minimally invasive esophagectomy (MIE) can reduce surgical trauma. A neck incision can be performed for extraction of surgical specimen. This study was performed to investigate the safety and feasibility of neck incision to extract surgical specimen in thoracolaparoscopic esophagectomy for esophageal cancer.

MATERIALS AND METHODS

Thirty-four patients who experienced thoracolaparoscopic esophagectomy for esophageal cancer and a neck incision for extraction of surgical specimen were enrolled. The clinical, surgical and follow-up data were analyzed.

RESULTS

The procedure was successful in all patients (100%), with a neck incision to extract the surgical specimen. The median surgical time was 309 min, and the median blood loss was 186 ml, with the mean length of hospital stay of 11.5 days. Pulmonary complications occurred in 8 patients (23.5%). Anastomotic leakage occurred in 5 patients (14.7%), with one patient being treated conservatively to recover and four (11.8%) who received interventional drainage. One patient with interventional drainage died of severe infection, resulting in a 30-day surgical mortality of 2.9% (n = 1). Gastrointestinal complications happened in 5 patients (14.7%), including ileus in three patients and anastomotic stenosis in two patients. Follow-up was performed at a median time of 20 months (interquartile range, 14-32 months), with no death during this period. No recurrence was found in the first 12 months after radical resection.

CONCLUSION

The cervical incision to extract surgical specimen is safe and feasible with improved cosmetic effect in thoracolaparoscopic esophagectomy for esophageal cancer.

Effect of preoperative radiotherapy on the prognosis of patients with stage cTxN0M0 esophageal squamous cell carcinoma: propensity score matching analysis based on SEER database

Objective

The aim of this study was to investigate the effect of preoperative radiotherapy (RT) on overall survival (OS) in patients with stage cTxN0M0 esophageal squamous cell carcinoma (ESCC).

Methods

A total of 467 patients with ESCC diagnosed as cTxN0M0 and undergoing esophagectomy between 2004 and 2016 were downloaded from the Surveillance, Epidemiology, and End Results (SEER) database. According to the presence or absence of preoperative RT, the patients were divided into preoperative RT group and non-preoperative RT group. Propensity score matching (PSM) was performed to equalize baseline levels between groups. Univariate and multivariate Cox regression analyses were used to compare the survival differences between the two groups.

Results

Using PSM, 162 pairs of patients were selected. Preoperative RT was not a prognostic factor for OS in all patients with cTx stage. After PSM, for patients with cT1-2 stage, univariate Cox regression analysis showed that preoperative RT was an influencing factor of OS, and multivariate Cox regression analysis confirmed that preoperative RT was an independent predictor of OS. Compared with non-preoperative RT, preoperative RT significantly decreased OS (HR = 1.556, 95%CI 1.008-2.464, p = 0.046). For patients with cT3-4, univariate Cox regression analysis showed that preoperative RT was an influencing factor for OS, and multivariate Cox regression analysis determined that preoperative RT was independent predictors of survival. Compared with non-preoperative RT, preoperative RT significantly improved the OS (HR = 0.479, 95%CI 0.272-0.841, p = 0.010).

Conclusion

For ESCC, preoperative RT can improve the OS of patients with cT3-4N0M0. However, preoperative RT is not suitable for patients with cT1-2N0M0.

Emergency tracheal intubation peri-operative risk factors and prognostic impact after esophagectomy

BACKGROUND

Emergent endotracheal intubation (ETI) is a serious complication after Oesophagectomy. It is still unclear that perioperative risk factors and prognosis of these patients with ETI.

METHODS

Between January 2015 and December 2018, 21 patients who received ETI after esophagectomy were enrolled (ETI group) at the department of thoracic surgery, Fujian Union hospital, China. Each study subject matched one patient who underwent the same surgery in the current era were included (control group). Patient characteristics and perioperative factors were collected.

RESULTS

Patients with ETI were older than those without ETI (p = 0.022). The patients with history of smoking in ETI group were significantly more than those in control group (p = 0.013). The stay-time of postanesthesia care unit (PACU) in ETI group was significantly longer than that in control group (p = 0.001). The incidence of anastomotic leak or electrolyte disorder in ETI group was also higher than that in control group (p = 0.014; p = 0.002). Logistic regression analysis indicated history of smoke (HR 6.43, 95%CI 1.39-29.76, p = 0.017) and longer stay time of PACU (HR 1.04, 95%CI 1.01-1.83, p = 0.020) both were independently associated with higher risks of ETI. The 3-year overall survival (OS) rates were 47.6% in patients with ETI and 85.7% in patients without ETI (HR 4.72, 95%CI 1.31-17.00, p = 0.018). COX regression analysis indicated ETI was an independent risk factor affecting the OS.

CONCLUSION

The study indicated that history of smoking and longer stay-time in PACU both were independently associated with higher risks of ETI; and ETI was an independent risk factor affecting the OS of patients after esophagectomy.

TRIAL REGISTRATION

This trial was retrospectively registered with the registration number of ChiCTR2000038549.

Adequate Management of Postoperative Complications after Esophagectomy: A Cornerstone for a Positive Outcome

BACKGROUND

Esophagectomy for cancer is one of the most complex procedures in visceral surgery. Postoperative complications negatively affect the patient's overall survival. They are not influenced by the histology type (adenocarcinoma (AC)/squamous cell carcinoma (SCC)), or the surgical approach (open, laparoscopic, or robotic-assisted). Among those dreadful complications are anastomotic leak (AL), esophago-respiratory fistula (ERF), and chylothorax (CT).

METHODS

In this review, we summarize the methods to avoid these complications, the diagnostic approach, and new therapeutic strategies.

RESULTS

In the last 20 years, both centralization of the medical care, and the development of endoscopy and radiology have positively influenced the management of postoperative complications. For the purpose of their prevention, perioperative measures have been applied. The treatment includes conservative, endoscopic, and surgical approaches.

CONCLUSIONS

Post-esophagectomy complications are common. Prevention measures should be known. Early recognition and adequate treatment of these complications save lives and lead to better outcomes.

Irradiation-induced exosomal HMGB1 to confer radioresistance via the PI3K/AKT/FOXO3A signaling pathway in ESCC

Background

Radioresistance is a major cause of treatment failure in esophageal squamous cell carcinoma (ESCC) radiotherapy, and the underlying mechanisms of radioresistance are still unclear. Irradiation (IR) stimulates changes in tumor-derived exosome contents, which can be taken up by recipient cells, playing an important role in the proliferation, cell cycle and apoptosis of recipient cells. This study investigated the effect of IR-induced exosomal high mobility group box 1 (HMGB1) on radioresistance in ESCC cells.

Methods

Plasma exosomes were isolated from 21 ESCC patients and 24 healthy volunteers, and the expression of HMGB1 was examined. Then, the therapeutic effect of radiotherapy was analyzed according to the different expression levels of plasma exosomal HMGB1 in ESCC patients. The uptake of exosomes by recipient cells was verified by immunofluorescence staining, and the localization of exosomes and HMGB1 in cells before and after IR was evaluated. The effects of IR-induced exosomes on cell proliferation, invasion, apoptosis, cell cycle distribution and radioresistance after HMGB1 knockdown were verified. Moreover, western blotting was used to measure changes in the expression of cyclin B1, CDK1, Bax, Bcl2, phosphorylated histone H2AX and the PI3K/AKT/FOXO3A pathway in the HMGB1-knockdown exosome group and the negative control group.

Results

The expression of HMGB1 in ESCC plasma exosomes was significantly increased compared with that in healthy volunteers, and high expression of HMGB1 in plasma exosomes was associated with radioresistance (P = 0.016). IR-induced the release of exosomal HMGB1 and promoted proliferation and radioresistance in recipient cells, with a sensitization enhancement ratio (SER) of 0.906 and 0.919, respectively. In addition, IR-induced exosomal HMGB1 promotes G2/M phase arrest by regulating the proteins cyclin B1 and CDK1, cooperating with the proteins Bax and Bcl2 to reduce the apoptosis rate through the PI3K/AKT/FOXO3A signaling pathway, and participated in IR-induced DNA damage repair through γH2AX.

Conclusion

These findings indicate that high expression of plasma exosomal HMGB1 is associated with an adverse radiotherapy response. IR-induced exosomal HMGB1 enhances the radioresistance of ESCC cells.

Construction of survival prediction model for elderly esophageal cancer

Background

The purpose of this study was to analyze the clinical characteristics and prognosis of EPEC and to construct a prediction model based on the SEER database.

Methods

All EPECs from the SEER database were retrospectively analyzed. A comprehensive and practical nomogram that predicts the overall survival (OS) of EPEC was constructed. Univariate and multivariate Cox regression analysis was performed to explore the clinical factors influencing the prognosis of EPEC, and finally, the 1 -, 3 - and 5-year OS were predicted by establishing the nomogram. The discriminant and predictive ability of the nomogram was evaluated by consistency index (C-index), calibration plot, area under the curve (AUC), and receiver operating characteristic (ROC) curve. Decision curve analysis (DCA) was used to evaluate the clinical value of the nomogram.

Results

A total of 3478 patients diagnosed with EPEC were extracted from the SEER database, and the data were randomly divided into the training group (n=2436) and the validation group (n=1402). T stage, N stage, M stage, surgery, chemotherapy, radiotherapy, age, grade, and tumor size were independent risk factors for 1 -, 3 - and 5-year OS of EPEC (P< 0.05), and these factors were used to construct the nomogram prediction mode. The C-index of the validation and training cohorts was 0.718 and 0.739, respectively, which were higher than those of the TNM stage system. The AUC values of the nomogram used to predict 1-, 2-, and 3-year OS were 0.751, 0.744, and 0.786 in the validation cohorts (0.761, 0.777, 0.787 in the training cohorts), respectively. The calibration curve of 1-, 2-, and 3-year OS showed that the prediction of the nomogram was in good agreement with the actual observation. The nomogram exhibited higher clinical utility after evaluation with the 1-, 2-, and 3-year DCA compared with the AJCC stage system.

Conclusions

This study shows that the nomogram prediction model for EPEC based on the SEER database has high accuracy and its prediction performance is significantly better than the TNM staging system, which can accurately and individually predict the OS of patients and help clinicians to formulate more accurate and personalized treatment plans.

Demystifying the Functional Role of Nuclear Receptors in Esophageal Cancer

Esophageal cancer (EC), an aggressive and poorly understood disease, is one of the top causes of cancer-related fatalities. GLOBOCAN 2020 reports that there are 544,076 deaths and 604,100 new cases expected worldwide. Even though there are various advancements in treatment procedures, this cancer has been reported as one of the most difficult cancers to cure, and to increase patient survival; treatment targets still need to be established. Nuclear receptors (NRs) are a type of transcription factor, which has a key role in several biological processes such as reproduction, development, cellular differentiation, stress response, immunity, metabolism, lipids, and drugs, and are essential regulators of several diseases, including cancer. Numerous studies have demonstrated the importance of NRs in tumor immunology and proved the well-known roles of multiple NRs in modulating proliferation, differentiation, and apoptosis. There are surplus of studies conducted on NRs and their implications in EC, but only a few studies have demonstrated the diagnostic and prognostic potential of NRs. Therefore, there is still a paucity of the role of NRs and different ways to target them in EC cells to stop them from spreading malignancy. This review emphasizes the significance of NRs in EC by discussing their diverse agonists as well as antagonists and their response to tumor progression. Additionally, we emphasize NRs’ potential to serve as a novel therapeutic target and their capacity to treat and prevent EC.

MIR548P and TRAV39 Are Potential Indicators of Tumor Microenvironment and Novel Prognostic Biomarkers of Esophageal Squamous Cell Carcinoma

Esophageal squamous cell carcinoma (ESCC) remains a common aggressive malignancy in the world. Multiple studies have shown evidence to support the hypothesis that certain functional genes that are engaged in the microenvironment of tumors played a role in the progression of ESCC. Thus, to better analyze the prognostic values of important genes in ESCC, there is an immediate need for an in-depth research study. From the TCGA database, the RNA-seq data and clinical features of 163 ESCC patients were obtained. Using the ESTIMATE technique, we were able to calculate the ImmuneScore, the StromalScore, and the ESTIMATEScore for each ESCC sample. The samples from the ESCC were split up into high score and low score groups based on the median of the various scores. In this study, ImmuneScore, StromalScore, and ESTIMATEScore were not found to be linked with overall survival of ESCC patients, according to our findings. Higher StromalScores were linked to more advanced T stages and clinical stages. The intersection analysis that was exhibited by the use of a Venn diagram indicated that there was a total of 944 upregulated genes that shared the same high score in both the ImmuneScore and the StromalScore and that there was 0 downregulated gene that shared the same low score. Survival experiments confirmed MIR548P and TRAV39 as critical prognostic biomarkers for ESCC patients. Importantly, we found that TRAV39 expression was positively associated with T cell CD4 memory activated while negatively associated with B cell memory, dendritic cells activated, and mast cells activated. In addition, we found that MIR548P expression was negatively associated with mast cells activated while positively associated with T cell CD4 memory activated. Overall, we identified MIR548P and TRAV39 as new modulators for ESCC, affecting the immune microenvironment of ESCC patients and may be a target of immunotherapy.

Study on the Application Value of Concurrent Chemoradiotherapy and Clinical Nursing Pathway for Postoperative Patients with Esophageal Cancer

Backgrounds

To observe the value of concurrent chemoradiotherapy and clinical nursing pathway for postoperative patients with esophageal cancer (EC).

Methods

A total of 88 postoperative EC patients were divided into the radiotherapy group (RG group, 44 cases) and the chemoradiotherapy group (CRG group, 44 cases). The RG group received single three-dimensional conformal radiotherapy+clinical nursing pathway, and the CRG group was combined with chemotherapy on this basis. The 5-year overall survival rate, progression-free survival rate, pathological remission and survival rate, lymph node metastasis and survival rate, quality of life analysis, tumor-related factor level, and incidence of adverse reactions were compared between the two groups.

Results

The overall survival rates at 1, 3, and 5 years were 93.18%, 56.82%, and 50.0% in the CRG group and 86.36%, 52.27%, and 43.18% in the RG group, respectively. The 5-year progression-free survival rate of the CRG group was 60.87%, which was clearly higher than that of the RG group (33.33%). The 1-, 3-, and 5-year overall survival rates of pCR and NpCR patients were 90.48%, 80.95%, and 61.90% and 89.55%, 44.78%, and 38.81%, respectively. The overall 1-year, 3-year, and 5-year survival rates were 81.08%, 37.84, and 24.32% and 96.08%, 66.67%, and 62.75% in patients with lymph node metastasis and nonlymph node metastasis, respectively, with statistical significant differences. The emotional function, physical function, cough, pain, and eating difficulty in the CRG group were better than those in the RG group. After treatment, serum CEA, SCC, CYFRA21-1, and CA199 levels in the CRG group were obviously downregulated compared with those in the RG group. There was no obvious difference in the incidence of adverse reactions between the CRG group and the RG group.

Conclusion

Single radiotherapy and concurrent chemoradiotherapy can be used as effective means in the treatment of EC. Moreover, the quality of life and survival time of the concurrent chemoradiotherapy group were dramatically better than those of the single radiotherapy group, and the antitumor ability of the concurrent chemoradiotherapy group was stronger.

Effect of different surgical approaches on the prognosis of patients with postoperative radiotherapy for stage IIB-IVA esophageal squamous cancer

Objective

To investigate the effect and clinical significance of different thoracic surgical approaches for patients with stage IIB–IVA esophageal squamous cell carcinoma on the survival and prognosis of postoperative radiotherapy patients.

Methods

One hundred thirty-two patients with stage IIB–IVA esophageal squamous cancer who received radiotherapy after surgery were screened for baseline characteristics and survival analysis. The Kaplan-Meier method was used to draw the survival curve for the follow-up data, and the log-rank test was used to compare the difference in survival rate between the two groups. The Cox regression model was used for multivariate survival analysis.

Result

For stage IIB–IVA esophageal squamous cell carcinoma, the results of multivariate analysis showed that different surgical methods and clinical staging were independent factors affecting the survival and prognosis of patients after radiotherapy. The 1-, 3-, and 5-year survival rates of patients with advanced esophageal cancer through the left chest approach were 84.2%, 61.4%, and 36.8% respectively. The 1-, 3-, and 5-year survival rates of patients with advanced esophageal cancer through the right chest approach were 73.3%, 40.0%, and 21.3% respectively. There was no significant difference in the 1-year survival rate (P = 0.135) between the two surgical procedures. The 3-year survival rate (P < 0.05) and the 5-year survival rate (P < 0.05) were significantly different.

Conclusion

For patients with stage IIB–IVA esophageal squamous cell carcinoma undergoing radiotherapy after surgery, the long-term survival prognosis of patients after the left thoracic approach is significantly higher than that of the right thoracic approach.

The 8th Wonder of the Cancer World: Esophageal Cancer and Inflammation

Esophageal cancer is a devastating malignancy which can be detected at an early stage but is more often diagnosed as an advanced process. It affects both men and women and inflicts the young and the elderly. There are multiple underlying factors involved in the pathogenesis of this cancer including inflammation. The interplay of these factors promotes inflammation through various mechanisms including the recruitment of pro-inflammatory cells, mediators such as cytokines, reactive oxygen species, and interleukins, among others. The presentation can vary widely with one of the most notable symptoms being dysphagia. Diagnosis is based on clinical symptomatology, imaging and endoscopy with biopsy. Once the diagnosis has been established, treatment and prognosis are based on the stage of the disease. This review outlines esophageal cancer and its link to inflammation in relation to pathogenesis, along with clinical features, diagnosis and treatment.

Tumor size predicts worse prognosis in esophagogastric junction adenocarcinoma

Adenocarcinoma of the esophagogastric junction (AEGJ) has an increasing incidence and is associated with limited overall survival. Several studies have tried to identify prognostic factors for AEGJ, although few have described relationships between prognosis and the tumor's size or anatomical location. Thus, this retrospective study evaluated 188 patients with resected locally advanced AEGJ. Tumor location was determined using upper endoscopy, and the following groups were created: E&E + EGJ (distal esophagus, esophagogastric junction, and distal esophagus), EGJ (esophagogastric junction), EGJ + G (esophagogastric junction and proximal stomach), G (proximal stomach), and E + EGJ + G (esophagus to the proximal stomach, including the esophagogastric junction). Other variables of interest were tumor size and differentiation, TNM stage, comorbidities, surgery type, and survival outcomes. Among 188 patients included, 163 were men (86.7%), and the mean age was 64.9 years. Forty-eight (25.6%) patients underwent total gastrectomy and distal esophagectomy, while 140 (74.4%) subtotal esophagectomy with proximal gastrectomy. Presence of comorbidities, tumor size, angiolymphatic and perineural invasion, and pTNM status were different between groups according to tumor location. The mean follow-up period was 47.4 months. The disease-free survival (DFS) rates were as follows: 72.7% (G), 68.0% (E&E + EGJ), 63.4% (EGJ), 57.1% (EGJ + G), and 44.4% (E + EGJ + G), while the overall survival (OS) rates were 81.0% (EGJ + G), 78.8% (G), 64.0% (E&E + EGJ), 54.9% (EGJ), and 48.1% (E + EGJ + G). Multivariate analysis revealed that tumor size of < 5 cm, and tumor location G subgroups were associated with better DFS. High histological grade and advanced pT status were independent factors related to worse OS. In conclusion, the prognosis of AEGJ may be preoperatively predicted by a tumor size of ≥ 5 cm and its anatomical location.

miR-498/DNMT3b Axis Mediates Resistance to Radiotherapy in Esophageal Cancer Cells

Objective: To explore the role of miR-498 in the radiotherapy resistance of esophageal cancer (EC) and its underlying mechanism. Methods: In vivo models of EC tissues with radioresistance or radiosensitivity were isolated from 72 EC patients who received radiotherapy. In vitro models were established after irradiation of KYSE30 cells. Quantitative reverse transcription polymerase chain reaction (qRT-PCR) and Western blot were employed to measure the expression levels of miR-498 and DNMT3b in EC cells sensitive or resistant to irradiation. Then, protein expression of DNMT3b was verified by immunohistochemistry. The cell viability, colony formation rate, and cell apoptotic rate of EC were correspondingly assessed by CCK-8, colony formation assay, and Annexin V/PI (propidium iodide) double staining. Western blot was utilized to perform the expression levels of PI3K, p-PI3K, AKT, and p-AKT in EC cell lines after irradiation. Results: Highly expressed DNMT3b and lowly expressed miR-498 were found in EC tissues. EC tissues with radiosensitivity had higher miR-498 level and lower DNMT3b expression than EC tissues with radioresistance. Overexpression of miR-498 or knockdown of DNMT3b enhanced the radiosensitivity of EC cells. DNMT3b was a target gene of miR-498. DNMT3b diminished the radiosensitization of miR-498 in EC cells. Conclusions: MiR-498 enhances the sensitivity of EC cells to radiation by DNMT3b inhibition, and exerts biological functions by inactivating the PI3K/AKT signaling pathway.

Immunotherapy Mechanism of Esophageal Squamous Cell Carcinoma with the Effect of STK11/AMPK Signaling Pathway

This study was aimed at exploring the mechanism of serine threonine protein kinase 11 (STK11)/Adenosine 5′-monophosphate-activated protein kinase (AMPK) signaling pathway after immunotherapy for esophageal squamous cell carcinoma (ESCC), providing basic information for the clinical treatment of ESCC. In this study, tissue specimens from 100 patients with ESCC who underwent surgical treatment in Taizhou People's Hospital (group A) and 20 patients with recurrent or metastatic ESCC who received second-line immunotherapy (group B) were collected. The real-time fluorescent quantitative polymerase chain reaction (PCR) (RT-qPCR) technology was used to detect the expression levels of STK11, interferon-γ (IFN-γ), interleukin 6 (IL-6), and vascular endothelial growth factor (VEGF) in the tissues. The immunohistochemical staining was used to detect the positive expression levels (PELs) of STK11 and AMPKα in the tissues, and immunofluorescence staining was used to detect the PELs Teff cells (CD3 and CD8), Treg cells (CD4 and FOXP3), and neutrophils (CD68 and CD163). RT-qPCR results showed that the expression levels of STK11 and IFN-γ in group A were obviously lower, and those of IL-6 and VEGF were much higher in contrast to group B (P < 0.05). The results of immunohistochemical staining showed that the number of STK11- and AMPKα-positive staining cells in group A was dramatically less than that in group B (P <0.05). The results of immunofluorescence staining revealed that the number of positive staining cells for Teff cells, Treg cells, and neutrophils in group A was also less dramatically than that in group B (P <0.05). In summary, immunotherapy can play a therapeutic effect on ESCC by regulating STK11/AMPK pathway and immune cell infiltration.

Prognostic variables for conditional survival in patients with esophageal squamous cell carcinoma who underwent minimally invasive surgery

Background

Esophageal squamous cell carcinoma (ESCC) survival is mainly reported at the time of treatment. Conditional survival is another prognostic tool to evaluate ESCC patients who has survived more than one year since treatment.

Methods

We analyzed data from 705 ESCC patients who underwent minimally invasive surgery between 2013 and 2016. Using the Kaplan–Meier method, we computed a 5-year relative conditional survival. We also investigated the prognostic factors associated with survival using Cox proportional hazards models.

Results

Conditional survival improved over time for all cohorts of ESCC patients who survived a period after surgery. The greatest improve in conditional survival were observed in patients 2 years after surgery. In addition, the results of the Cox survival model from the time of surgery, T stage (p < 0.001), N stage (p < 0.001), and anastomotic leak (p = 0.022), were significantly associated with survival. However, the results of the Cox survival model from 2 years after surgery, N stage (p < 0.001), and anastomotic leak (p = 0.032) were significantly associated with survival.

Conclusion

For ESCC patients who survived a period after surgery, the largest increases in conditional survival were observed in patients 2 years after surgery. We suggest that patients with anastomotic leakage and higher T and N stages should be strictly screened according to various time, and that conditional survival should be used as a powerful prognostic tool for ESCC patients.

Update on Management of Squamous Cell Esophageal Cancer

PURPOSE OF THE REVIEW

Esophageal cancer is the sixth most common cause of cancer death globally. Squamous cell carcinoma of the esophagus (ESCC) is the predominant histologic type in the world. Treatment strategies have evolved in the last decade and new paradigms are replacing traditional approaches at all stages of cancer. This review will summarize the epidemiology, diagnosis, staging, and treatment of esophageal squamous cell carcinoma.

RECENT FINDINGS

Novel approaches to screening may be cost-effective in regions with a high incidence of ESCC. Multi-disciplinary evaluation and treatment has become the standard of care. Endoscopic resection may be an option for early stage ESCC. Minimally invasive esophagectomy can be performed safely as a primary therapy or after-induction chemoradiation. Several recent studies have found a survival benefit to immunotherapy for patients with metastatic or persistent disease. Multi-disciplinary evaluation and multi-modal therapy including cytotoxic chemotherapy, radiation, surgery, and immunotherapy have improved survival compared to surgery alone.

Molecular mechanisms associated with chemoresistance in esophageal cancer

Esophageal cancer (EC) is one of the most incident and lethal tumors worldwide. Although surgical resection is an important approach in EC treatment, late diagnosis, metastasis and recurrence after surgery have led to the management of adjuvant and neoadjuvant therapies over the past few decades. In this scenario, 5-fluorouracil (5-FU) and cisplatin (CISP), and more recently paclitaxel (PTX) and carboplatin (CBP), have been traditionally used in EC treatment. However, chemoresistance to these agents along EC therapeutic management represents the main obstacle to successfully treat this malignancy. In this sense, despite the fact that most of chemotherapy drugs were discovered several decades ago, in many cases, including EC, they still represent the most affordable and widely employed treatment approach for these tumors. Therefore, this review summarizes the main mechanisms through which the response to the most widely chemotherapeutic agents used in EC treatment is impaired, such as drug metabolism, apoptosis resistance, cancer stem cells (CSCs), cell cycle, autophagy, energetic metabolism deregulation, tumor microenvironment and epigenetic modifications.